The definition of sore throat varies between anesthesiologists and the severity varies among patients as it is mainly subjective and depends on one’s tolerance to pain. The insult is said to be multifactorial in origin including the size of the device selected, cuff design, the pressure generated, duration of surgery being a few leading to mechanical contact, and abrasion by the SAD in and around the glottic area (Endo et al. 2007). In ref (Endo et al. 2007), chose surgeries lasting for about 60 to 120 min under GA as a longer duration per se can contribute to PLM (Endo et al. 2007). Sore throat following the use of a laryngeal mask appears to be related to the technique of insertion, but the high intracuff pressure generated can lead to nerve palsies due to neuropraxia and nerve compression like the hypoglossal nerve palsy leading to dysphagia, dysarthria, and immobility of the tongue (Endo et al. 2007). SADs are intrinsically more invasive than a facemask but less invasive than tracheal intubation, and careful insertion techniques particularly for laryngeal mask insertion are of paramount importance in the prevention of PLM (Venugopal et al. 2016a). Studies have demonstrated a significant reduction in the incidence of POST and cough when ETT was smeared with betamethasone gel (Sumathi et al. 2008; Selvaraj and Dhanpal 2002). The beneficial effect of steroid gel application was attributed to the widespread effect of the drug on all portions of the tube that came in contact with the posterior pharyngeal wall, vocal cords, and trachea and not just confined to the tip and cuff of the tracheal tube (Selvaraj and Dhanpal 2002). Since the I-gel does not have a cuff to be inflated, the incidence of PLM is expected to be further less than the LMA in the post-operative period.

PLM is better prevented than treated. The incidence has reduced drastically with the availability of a newer generation of SADs which varies in cuff design, shape, and material, and better lubricating agents available like steroid gel. Cuffless SADs like I-gel provides an optimum seal at the laryngeal aperture with less pressure required for positive pressure ventilation which has recently gained recognition as an airway management device both in elective as well as emergencies. In a significant study of data-based systematic review done by Tanaka et al. using lidocaine as a topical preparation, the incidence of PLM was found to be significantly lower (Tanaka et al. 2015). In another interesting study, the incidence of PLM was found to be higher in women than men (Jansson et al. 2014).

In a study by Kiran.S et al., it was found that betamethasone gel resulted in a significantly lower incidence of PLM compared to 2% Lidocaine jelly, but they used Proseal LMA as the SAD (Kiran et al. 2012). Gupta et al. in their study found that the use of Strepsils lozenges resulted in a 20% reduction in the post-operative cough which was statistically significant (Gupta et al. 2014). Gargling ketamine 50 mg for the 40 s just 5 min before induction of GA and intubation was found to reduce the incidence and severity of POST in a significant way (Rudra et al. 2009). Similar results were also found with the use of oral dispersible Zinc tablets and magnesium lozenges in ameliorating POST (Sarkar and Mandal 2020; Singh et al. 2019). Rieger et al. showed that the incidence of PLMs was not directly related to the intracuff pressure transmitted to the mucosa (Rieger et al. 1997). Although hoarseness of voice seems to be a trivial adverse effect, along with sore throat and dysphagia it can lead to significant patient discomfort, anxiety, and postoperative morbidity following intubation (Ebneshahidi and Mohseni 2010). Like LMA, I-gel insertion can also lead to dislocation of the arytenoid joints causing hoarseness of voice or it may be following vocal cord paralysis which may be unilateral or bilateral (Brimacombe 1997). None of our patients had severe grades of POST according to the questionnaire. Only two cases out of 118 had a traumatic placement which was noted as a bloodstain on the dorsum of the I-gel at the end of the procedure. SADs with I-gel in particular are expected to have a lower incidence of PLM. Since the device is bulky because of the cuff, it may cause abrasive injuries in the pharyngeal mucosa if not placed gently and well lubricated. Also in patients with limited mouth opening and larger tongue where I-gel is inserted with difficulty, it can lead to abrasive injuries of the mucosa, unlike LMA which requires less space for insertion as the cuff is deflatable. Betamethasone gel acts as a lubricating agent with additional anti-inflammatory effects at the site of insult like the pharyngeal mucosa. This research work found that the outcome was comparable to lidocaine jelly used I-gel as the SAD which is cuffless and less likely to cause pharyngeal trauma, unlike other studies where either ETT or LMAs were used. But, surprisingly in a cross-sectional observational study on the incidence of POST following LMA and I-gel, it was found that both the incidence and severity were more with I-gel (Lin et al. 2020).

Regarding limitations of our study, chose only breast patients for mastectomy to limit the duration of surgery where positioning is supine and surgical duration is expected to be less than 120 min. A larger study taking other types of cases requiring positioning other than supine, an extended duration of surgery, obesity and pediatric cases taken as subsets or confounding factors may reveal whether they have a higher propensity to PLM. We didn’t have a control group with KY jelly applied over the device. We had only one male patient for mastectomy out of 118 cases and hence cannot comment whether the sex of the individual had any role in the contribution of PLM.